Out-patient Patient Care Navigators

Laura Burchell is a registered nurse with a BA in gerontology. For the past three years, she has been the Geriatric Care Navigator at Dartmouth General Hospital in Nova Scotia.

Emergency departments are one of the least friendly environments for older dementia patients.

The program was introduced six years ago as part of a government-funded pilot project. Since then, the funding has been cut and the hospital covers all costs, so Burchell is now the only navigator on the team.

She serves people in the Dartmouth area who are over 65 and have some element of frailty (cognitive impairment, chronic illness, mobility issues, for example) that make living independently difficult or impossible. Many of the people she sees are living with dementia.

“As I see it, the role of the navigator is to do a thorough assessment of frail elderly to determine resources and services that can be put in place to maintain independence at home, and healthy living in general, for as long as they choose,” says Burchell.

That goal is not only good for the patient, it’s good for our health care system: If people are admitted to hospital, but can’t return home after treatment, discharge can be delayed. That means longer wait times for others who need the acute care hospital bed. It’s also more expensive to “house” people in hospitals than to get them into a long-term care facility or to provide assistance in their own home.

Burchell’s patients don’t need a referral from a doctor. Patients or their caregivers can apply online to have an assessment. Burchell receives these requests and triages them, prioritizing patients based on their description of their situation.

She spends a large part of her workday in her car, visiting people in their homes where she conducts cognitive testing, mobility and functional assessments and home safety evaluations. But first there is conversation.

“We’re not bound by a certain amount of time for each visit. We just sit and have a chat,” she says. “I find with seniors they like to tell their stories. Seniors put on that very stoic mask, but as they tell stories, you garner insight into the true nature of the difficulties they are having.”

The mini mental status exam is the test she administers most often, “just to create a baseline of functioning,” says Burchell.

But she can also administer the Frontal Assessment and the Montreal Cognitive Assessment in her patients’ home.

What Happens Next

Some patients have already been diagnosed with dementia, but circumstances have changed. For example, she has patients who have been on a waiting list for a long-term care bed, and as their physical condition has deteriorated as months passed, their situation has become dire.

“I help them link with the care coordinator for another assessment,” says Burchell. “Maybe mom can be bumped up the list if she becomes an urgent placement.” In cases where that’s not possible, Burchell can connect with local health authorities to get the patient reassessed with an eye to qualifying for more government-funded in-home care.

After Burchell’s assessments are done, she forwards her findings to the patient’s primary care physician. If follow-up is needed—a referral to a geriatrician, physiotherapist or other specialist, for example—the doctor does that. Even if no follow-up is recommended, Burchell’s findings can help the physician.

“Family doctors used to have time to see the whole picture, they did routine home visits to check in on patients, and now they don’t,” she says. “I’m their eyes. They may think life is rosy for Ms. Smith, but often it isn’t.”

For her patients with dementia, the caregiver is often present at assessments and much of the help Burchell sources is directed at them. “We create coping strategies,” she says. “Maybe they don’t know what to do because mom wanders, so I help them come up with strategies so they can sleep at night.”

Such as? “Sensors on the doors, for example. People don’t realize that’s an option.” She’s spent many hours educating people on various safety alerts not only for appliances and falls, but for medication dispensers, too, all of which are protection that help a person living with dementia stay safely at home.

Burchell doesn’t remember how many clients she’s seen since she started this job, and when it comes to the number of referral forms waiting for her to triage, all she’s sure of is that “there are more than I can count.”


• You’ll find patient care navigators in the private system, but public hospitals, clinics and family practice centres also offer patient care navigator services.

See Hospitals, Emergency and the Dementia Patient, to see how it works well at one health institution.

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About the author

Jasmine Miller

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